History of the facelift

The facelift by era

1901 to the 1930s: cutting out skin

Eugen Hollander said in 1932 that he had performed the first facelift in 1901, on a Polish aristocrat; his first written mention of the operation came in 1912 (Barrett 2016, full text). Hollander and Erich Lexer worked independently in Germany. Hollander only cut out skin. Lexer lifted the skin over several centimeters and anchored his stitches in the fascia of the temple for a lasting hold, which is why he is regarded as the first to practice the modern operation (PMID 32408370). Lexer later reported a 1906 lift on an actress, and Charles Miller, possibly the first American to do the operation, published his methods in 1907 (Barrett 2016, full text).

Suzanne Noel performed a facelift in France in 1912 (PMID 38809028). Her "petit operation" set rules that short-scar facelifts still follow: hide the incision in the hairline, keep it short, put no tension on the skin, handle the skin edges gently, set the direction of pull precisely and stage the work when needed (PMID 31637506).

The First World War pushed the field forward. Surgeons rebuilt the faces of wounded soldiers, and in France that work, begun by Morestin, led to the facelifts of Passot, Noel and Bourguet between the wars (PMID 20869800). Bourguet was the first to describe lifting the skin away from the tissue beneath it, and in 1920 Bettman described one continuous incision from the temple scalp, in front of the ear, behind it and onto the mastoid, close to the one used today (Barrett 2016, full text). Joseph moved the incision behind the tragus in 1928 (Barrett 2016, full text), and in 1927 Bames described undermining and redraping the skin (PMID 26430622).

What went wrong with the skin-only lift

Skin stretches. A lift that tightens only the skin leaves the sagging tissue underneath where it was, and the skin, closed under tension, relaxes and loses the effect (Barrett 2016, full text, Kim 2015, full text). Skin-only lifts also did nothing for the sagging midface (Barrett 2016, full text). Their known drawbacks include a tight, mask-like look, a distorted earlobe or hairline, widened scars and loss of skin at the flap edges (Kim 2015, full text).

A review of facelifts done from 1962 to 1973 named hematoma, skin loss and facial nerve damage as the major complications, and found patients more troubled by numbness, hair loss, scarring and general dissatisfaction (PMID 847029). In a 1973 study at one hospital, 3.26% of patients under general anesthesia needed a return to surgery for bleeding (PMID 8171138). Men bled more: Baker found large hematomas in men more than twice as often as in women (PMID 909960), and published rates in men ran from 7.9% to 12.9% (PMID 16327611).

1960 to 1980: the deeper layer

By the 1960s surgeons were working under the skin to make up for the limits of the skin-only lift; Aufricht promoted stitching the tissue below the fat in 1960 (Barrett 2016, full text). Skoog then lifted the layer under the cheek fat together with the platysma of the neck as one unit, moved it up and back and fixed it there; he presented the method in 1973 and published it in 1974 (Kim 2015, full text). Lemmon and Hamra reported five years of Skoog lifts in 1980 (PMID 7355165).

In 1976 Mitz and Peyronie dissected cadavers and named that layer the superficial musculoaponeurotic system, the SMAS (PMID 935283). They also warned that lifting under the SMAS is safe over the parotid gland in front of the ear and can become dangerous further forward (PMID 935283). Mitz looked back on those fifty years in 2026 (PMID 42481023).

The neck got its own operations in the same years: a muscular lift of the neck (PMID 4843119), the platysma-fascial lift (PMID 928549) and platysma muscle flaps to remove neck bands (PMID 365042). In 1980 Ellenbogen set out what a youthful neck looks like, and argued that tightening the platysma at the front of the neck matters more than pulling it from behind, and that in a heavy neck the fat under the muscle has to come out (PMID 7443846). Owsley joined face and neck in the SMAS-platysma facelift of 1983 (PMID 6828592).

The deeper lift was not proven better at first. Split-face studies in 1974 and 1977, with a skin-only lift on one side and a SMAS lift on the other, found no visible difference (PMID 4832464, PMID 928550), though they lacked standard measurements (Barrett 2016, full text). In 1979 Baker and Conley put facial nerve injury below 1%, with most patients recovering within six months, and warned that the new deeper dissections raised the risk (PMID 515227).

1989 to 2002: ligaments and the deep plane

Anatomy changed the operation again. In 1989 Furnas described the retaining ligaments that tie the cheek skin to the bone, and showed they must be released for the skin to move upward fully (PMID 2909050). In 1992 Stuzin, Baker and Gordon described the face as layers and showed that the facial nerve branches in the cheek lie beneath the deep fascia (PMID 1741467). That map is what makes a deep dissection safe.

Facelifts had long done little for the fold between the nose and the mouth. In 1990 Sam Hamra carried the dissection under the SMAS over the cheek muscles and past that fold, and lifted skin, cheek fat and platysma as one thick flap: the deep-plane facelift (PMID 2359803). In 1992 he added the muscle around the eye to the flap, the composite facelift (PMID 1615067). Other surgeons attacked the same fold in other ways: releasing the SMAS from the cheekbone and stitching it back to the bone (PMID 1561253), a higher SMAS dissection (PMID 1409995, PMID 19332004), lifting the cheek fat pad (PMID 8438018) and extending the SMAS flap into the midface (PMID 7634739, PMID 8526157).

A third route went under the bone lining. Tessier's subperiosteal "mask lift" of 1989 freed the whole soft tissue of the cheek from the bone (PMID 2473674). The earlier subperiosteal method had a high rate of nerve injury, and Ramirez changed the dissection in 1991 to make it safer (PMID 1852815), then did it through an endoscope in 1994 (PMID 7817884). Mendelson mapped the spaces of the cheek and jaw: the jowl forms as the space over the lower jaw muscle stretches with age (PMID 12172155, PMID 18183455).

What the deeper lifts taught

• More surgery did not always mean a better result. In a 1996 split-face study, the composite flap looked most dramatic on the operating table, but the difference was gone within a day and could not be seen at 6 or 12 months; the authors judged the extra risk and recovery not warranted for the average patient (PMID 8942899).
• Some areas relapse faster than others. When Hamra re-examined his original deep-plane patients years later, the jawline lift had held and the improvement in the fold beside the mouth had faded (PMID 12172164).
• Pulling sideways makes a face look operated on. Hamra showed that a lift pulled only toward the ear tightens the jawline while the cheek above keeps falling, which produces the swept, pulled look; lifting up and inward prevents it (PMID 9774028, PMID 11802570).
• Smaller operations raised questions about durability. Deeper lifts took longer and healed slower, and the reaction was the minimal-access lift: Tonnard and Verpaele's MACS lift of 2002 suspends the tissue with purse-string stitches anchored at the temple, under local anesthesia through a short incision (PMID 11994618). Its early results matched SMAS lifts, and its durability has been questioned (Barrett 2016, full text). Barbed thread lifts were marketed as non-surgical, and only about a third of patients kept most of the effect at one to two years (Barrett 2016, full text).

1995 to 2014: putting volume back

Aging also takes away volume, and lifting does not put it back (PMID 24569422). In 1995 Coleman published controlled demonstrations that fat moved within the body survives long term in the face (PMID 8526158). In 2007 Rohrich and Pessa showed that facial fat sits in separate compartments (PMID 17519724), and in 2014 Rohrich combined SMAS lifting with fat grafts placed into those compartments, the lift-and-fill facelift; the fold beside the mouth improved by at least one grade in about 4 in 5 patients (PMID 24569422). Board case data show fat grafting with facelifts and patient concern about volume loss both rising (PMID 38302713).

Why the facelift is safer now

• Bleeding. High blood pressure after surgery was identified as a key cause of hematoma in 1976 (PMID 16327611). At one hospital, the rate of hematoma needing surgery under general anesthesia fell from 3.26% in 1973 to 1.11% in 1994, a change credited to avoiding low blood pressure during the operation (PMID 8171138). In men, a strict blood pressure regimen cut it from 8.7% to 3.97% (PMID 16327611).
• The hemostatic net. In 2014 Auersvald and Auersvald borrowed a quilting stitch from tummy tucks: a running stitch through the skin and SMAS that closes the space where blood collects. Their patients with the net had no hematoma in the first three days, against 14.2% in their earlier patients (PMID 23949130). A randomized trial later found the net and drains equal for hematoma (PMID 40131398), and the method, renamed the surgical net, is now used beyond the face (PMID 38806160).
• Nerves. With the layers mapped (PMID 1741467), pooled data put motor nerve injury after facelift at 0.66%, and permanent injury at about 1 in 2,000 (PMID 40456989). Pooled deep-plane studies found no permanent nerve injury (PMID 42576065).
• Overall. In a US registry, about 2 in 100 facelift patients had a complication that needed emergency care, a hospital stay or a return to surgery, with hematoma the most common (PMID 26578747). The remaining risk rises with combined procedures, long operations, smoking, obesity, male sex, general anesthesia and office-based surgery (PMID 32459769).

The facelift today

• Deep plane leads among facial plastic surgeons. In a national survey, 9 in 10 responding facial plastic surgeons performed deep-plane facelifts, and surgeons with fewer years in practice were more likely to; the survey did not link deep plane to longer-lasting results (PMID 41251721). Plastic surgeons tracked by their certifying board most often used SMAS plication and SMAS flaps, and skin-only lifts made up 8% (PMID 38302713).
• The lift runs into the neck. Jacono combined deep-plane release with a vertical pull and a cut in the side of the platysma so the cheek and jaw move straight up while the neck is pulled up and back in its own direction (PMID 22065880). Extended deep-plane and vertical neck lifting release the platysma from its neck ligaments (PMID 32937672).
• The deep neck is treated directly. O'Daniel measured what comes out in deep neck lifts: most of the volume lies under the platysma, in deep fat, the submandibular glands and the digastric muscles (PMID 33543747). He later set gland reduction out in seven steps (PMID 42759497). Cadaver work showed the platysma gets its nerves in segments, which explains lower-lip weakness after some neck lifts and the return of bands (PMID 37186556).
• Hidden incisions. Endoscopic deep-plane lifts through short, hidden incisions report no permanent nerve injury in long single-surgeon series (PMID 40576459, PMID 38152870).
• More second facelifts. Board case data show the share of secondary facelifts rising (PMID 38302713).

Questions to ask a surgeon

• Which layer carries my lift: the skin, the SMAS, or a deep-plane flap? (PMID 29204547)
• In which direction will you lift, and how do you avoid a pulled, sideways look? (PMID 11802570)
• Do I need volume added as well as lifting, and where would the fat come from? (PMID 24569422)
• How do you control my blood pressure and bleeding during and after surgery? (PMID 8171138)
• Will my neck be treated under the muscle, or only the skin and muscle? (PMID 33543747)
• Which parts of the lift last longest in your patients, and which relax first? (PMID 12172164)

Open questions

• No technique is the standard: the options give comparable results, and which is best may differ by patient (PMID 29204547).
• Deeper against simpler SMAS lifts: a split-face comparison found no difference at a year (PMID 8942899), and the national survey found no link to longevity (PMID 41251721).
• Who did the first facelift: Hollander's 1901 date comes from his own 1932 account (Barrett 2016, full text); Lexer is credited with the first modern technique (PMID 32408370).
• Skoog's date: presented in 1973, published in 1974 (Kim 2015, full text).
• Bames's 1927 paper is not in PubMed; the citation comes from a later review's reference list (PMID 26430622).

History reviews

• Barrett, Casanueva and Wang 2016, the evolution of the rhytidectomy (PMID 29204547).
• Mangat and Frankel 2017, the history of rhytidectomy (PMID 28571059).
• Charafeddine 2019, facelift history and anatomy (PMID 31514803).
• Hashem 2020, history, anatomy and clinical assessment (PMID 30843042).
• Luu and Friedman 2021, history, anatomy and recent innovations (PMID 32937672).
• Kim 2015, thirty years of face lifts (PMID 26430622).
• Labbé 2010, French contributions to facial aesthetic surgery (PMID 20869800).
• A 1927 account of cosmetic surgery, reprinted in 2000 (PMID 11039392).

Terms

• Rhytidectomy, meloplasty: medical names for the facelift (PMID 28571059).
• Subcutaneous facelift: a skin-only lift, the skin freed from the tissue beneath and pulled tight (PMID 29204547).
• SMAS: the layer of fibrous tissue and muscle under the facial fat, continuous with the platysma of the neck (PMID 935283).
• Retaining ligaments: fibrous ties from bone to skin that hold the cheek in place (PMID 2909050).
• Deep plane: the space under the SMAS, entered to release the ligaments and lift skin, fat and SMAS together (PMID 2359803).
• Composite facelift: a deep-plane lift that also moves the muscle around the eye (PMID 1615067).
• Subperiosteal lift: a lift under the bone lining of the cheek (PMID 2473674).
• Lateral sweep: the pulled look left by a lift drawn only toward the ear (PMID 9774028).
• Hematoma: blood that collects under the lifted skin (PMID 23949130).
• Platysma: the thin sheet of muscle across the front of the neck (PMID 37186556).

Papers